Peter Fonagy, beside having given important contributions in
various areas, is also a very well known researcher in one of the most
interesting and promising fields, the research on attachment. Like Mary
Main and other heirs of Bowlby, he continued to explore this line of
research, and investigated the concept of "metacognition"
(what he calls "reflective self function"), which attracts
more and more the attention not only of psychoanalysts but also of researchers
of the cognitive field. To this regard, we can say that maybe Fonagy,
a leading figure in contemporary psychoanalysis, more than any
other author contributed to the rich dialogue between analysts and cognitive
therapists that we see today. This article we have chosen for publication
in PSYCHOMEDIA is one of his clearest and most comprehensive
papers, in which he shows an overview of the main issues of his research
as well as its relevance for the understanding of personality disorders.
The second part of this article (starting with paragraph 3.1) was published,
with the slightly different title "Attaccamento sicuro e insicuro",
in the Italian journal KOS, 1996, 129, June, pp. 26-32. An English
version, written in 1997, will appear in: Maffei C., Derksen J. &
Groen H. (editors), Treatment of Personality Disorders (New York:
Plenum Press, in press). We thank the Italian journal KOS
and Peter Fonagy for having given the texts
and the publications permissions.

Attachment theory concerns the nature of early experiences of children
and the impact of these experiences on aspects of later functioning
of particular relevance to personality disorder. The question we attempt
to address here is how deprivation, in particular early trauma, comes
to affect the individuals propensity to personality disorder.
As part of this question we are naturally also concerned to understand
how such adverse consequences may be avoided. The key assumption made
by the invoking of attachment theory is that individual social behaviour
may be understood in terms of generic mental models of social relationships
constructed by the individual. These models, although constantly evolving
and subject to modification, are strongly influenced by the childs
experiences with the primary caregivers. Let us now turn to the details
of the theory.

2. The nature of the attachment system

Attachment theory, developed by John Bowlby (1969, 1973, 1980), postulates
a universal human need to form close affectional bonds. It is a normative
theory of how the attachment system functions in all humans.
Bowlby described attachment as a special type of social relationship,
paradigmatically between infant and caregiver, involving an affective
bond. More significantly, it may also be seen as the context within
which the human infant learns to regulate emotion (Sroufe, 1990).

The stability of early childhood attachment patterns is well demonstrated.
Mary Ainsworth and her colleagues (Ainsworth, 1985; Ainsworth &
Wittig, 1969; Ainsworth et al., 1978) developed a procedure commonly
known as the Strange Situation, which classifies infants and
toddlers into one of four attachment categories. Secure infants
explore readily in the presence of the primary caregiver, are anxious
in the presence of the stranger, are distressed by their caregivers
departure and brief absence, rapidly seek contact with the caregiver
following a brief period of separation, and are reassured by renewed
contact. The recovery from an over-aroused disorganised state is smooth
and carried to completion in the sense that the infant returns to exploration
and play.

Some infants, who are usually made less anxious by separation, do not
automatically seek proximity with the caregiver on her return following
separation and may show no preference for the caregiver over the stranger;
these infants are designated Anxious/Avoidant. A
third category, the Anxious/Resistant infant manifest
impoverished exploration and play, tend to be highly distressed by separation
from the caregiver, but have great difficulty in settling after reunion
showing struggling, stiffness, or continued crying, or fuss in a passive
way. The caregivers presence or attempts at comforting fails to
offer reassurance and their anxiety and anger appears to interfere with
their attempts to derive comfort through proximity. Both these insecure
groups appear to be coping with arousal and ambivalence through a precautious
over-control of affect because they appear to be uncertain in their
expectation that the caregiver will do his or her part to modulate their
emotional arousal (Main & Weston, 1981; Sroufe, 1990).

It is generally held that the patterning of attachment related behaviour
is underpinned by different strategies adopted by children to regulate
their emotional reactions. As affect regulation is acquired with the
help of the childs primary caregiver, the childs strategy
will be inevitably a reflection of the caregivers behaviour towards
him/her. Secure infants behaviour is based on the experience of
well co-ordinated, positive interactions where the caregiver is rarely
over-arousing and is able to restabilise the childs spontaneously
emerging disorganising emotional responses. Therefore, they remain relatively
organised in stressful situations. Negative emotions are not seen as
threatening in and of themselves but are regarded by the infant as serving
a communicative function (Grossman et al., 1986; Sroufe, 1979,
1996).

By contrast, Anxious/Avoidantly attached children are presumed to have
experiences when their emotional arousal was not restabilised by the
caregiver because of personal or social pressures on the caregiver and
an associated mild neglect or even resentment of the child. The same
expectations may arise in children who were over aroused through intrusive
parenting, therefore they over-regulate their affect and steer
away from situations that are likely to be emotionally arousing. Anxious/Resistantly
attached children under-regulate, heightening their expression
of distress possibly in an effort to elicit the expectable response
of the caregiver. These children have low thresholds for threat and
may become preoccupied with having contact with the caregiver, but show
signs of frustration regarding this contact even when it is available
(Sroufe, 1996).

A fourth group of infants appear to exhibit a range of seemingly undirected
behavioural responses giving the impression of disorganisation and disorientation
(Main & Solomon, 1990). Infants who manifest freezing, handclapping,
headbanging, the wish to escape from the situation even in the presence
of the caregiver, are referred to as Disorganised/ Disoriented.
It is generally held that for such infants the caregiver has served
both as a source of fear and as a source of reassurance, thus the arousal
of the attachment behavioural system produces strong conflicting motivations.
Not surprisingly, a history of severe neglect or physical or sexual
abuse is often associated with the manifestation of this pattern (Cicchetti
& Beeghly, 1987; Main & Hesse 1990).

2.1 Determinants of attachment security

It is beyond the scope of this paper to consider in detail the rich
literature on determinants of infant security. There are many excellent
reviews available, notably by Belsky (Belsky et al., 1995). Clearly
genetic transmission may account for some component of the prediction
from parental attachment status to the childs security of attachment
(van Ijzendoorn, 1992). The influence of temperament on attachment security
is controversial, but the balance of the evidence is now against the
appropriateness of a temperamental account (Kagan, 1982; Lamb et
al., 1984). There is little evidence that distress-prone infants
become anxious-resistant babies (van den Boom, 1990). Temperament changes
in the first year of life (Belsky et al., 1991) and the attachment
pattern of a child to his two parents is often inconsistent (Fox et
al., 1991) and appears to be dependent on the internal working model
of each parent (Steele et al., 1996).

Negative parental personality traits are associated with insecurity
in many studies, although by no means all (Zeanah et al., 1993).
This has been shown for anxiety (Del Carmen et al., 1993), aggression
(Maslin & Bates, 1983) and suspicion (Egeland and Farber, 1984).
Parental psychopathology is also found to be a risk factor in some studies
(Campbell et al., 1993). Of the contextual factors, support from
the partner (Goldberg and Easterbrooks, 1984) and from others in the
mother's environment (Crnic et al., 1983) appear important. The
strength of these associations is reinforced by experimental studies
where social support was systematically manipulated (Lyons-Ruth et
al., 1990; Jacobson & Frye, 1991; Lieberman et al., 1991).

These predictors of infant security are correlated to one another and
are all likely to be unequally distributed across socio-economic groups.
It is known that socio-economic status and other indicators of social
deprivation are linked to both infant and adult classifications (e.g.
Ward & Carlson, 1995; van Ijzendoorn & Kroonenberg, 1988; Crittenden
et al., 1991; Zeanah et al., 1993). Poor parenting skills
and the maltreatment of children are more common in families suffering
economic hardship (Gabarino, 1992). Insecure classification is more
common in deprived groups. Maltreatment of children, strongly associated
with economic deprivation (Belsky, 1993) is most likely to be associated
with the disorganised/disoriented pattern of infant attachment.

2.2 The continuity of patterns of attachment

Bowlby proposed that the quality of childhood relationships with the
caregivers results in internal representations or working models of
the self and others that provide prototypes for later social relations.
Internal working models are mental schemata, where expectations about
the behaviour of a particular individual toward the self are aggregated.
The expectations are themselves abstractions based on repeated interactions
of specific types with that individual. If the childs physical
injury is quickly dealt with, sources of unhappiness are rapidly addressed,
the child will develop the legitimate expectation that, with that person
at least, his distress is likely to be met by reassurance and comforting.
The internal working model is the result of a natural process of abstraction
of the invariant features from diverse social situations with a particular
individual (Stern, 1985, 1994).

Such internal models of attachment remain relatively stable across
the lifespan (Collins & Read, 1994). Secure children, with the benefit
of well-regulated caregiver-infant relationships behind them, are expected
to evolve positive expectations concerning their exploratory competence,
to achieve a reliable capacity for modulation of arousal, a good capacity
for communication within relationships and, above all, confidence in
the ongoing availability of the caregiver. Early experiences of flexible
access to feelings is regarded as formative by attachment theorists,
enabling secure children both to maximise the opportunities presented
to them by the environment and draw on socially supportive relationships.
The autonomous sense of self emerges fully from secure parent-infant
relationships (Emde & Buchsbaum, 1990; Lieberman and Pawl, 1990;
Fonagy et al., 1995). The increased control of the secure child
permits it to move towards the ownership of inner experience and come
to recognise the self as competent in eliciting regulatory assistance,
to develop metacognitive control and to achieve an understanding of
self and others as intentional agents whose behaviour is organised by
mental states, thoughts, feelings, beliefs and desires (Sroufe, 1990;
Fonagy et al., 1995).

2.3 Prediction from adult attachment measures

The stability of these attachment assessments are dramatically illustrated
by longitudinal studies of infants assessed with the Strange Situation
and followed up in adolescence or young adulthood with the Adult
Attachment Interview (AAI) (George et al., 1985). The AAI
asks subjects about childhood attachment relationships and the meaning
which an individual currently gives to attachment experiences. The instrument
is rated according to the scoring system developed by Main & Goldwyn
(1994) which classifies individuals into Secure/Autonomous, Insecure/Dismissing
or Avoidant, Insecure/Preoccupied or Resistant or Unresolved/Disorganised
with respect to loss or trauma, categories according to the structural
qualities of their narratives of early experiences. (While autonomous
individuals clearly value attachment relationships and regard these
as formative, insecure individuals are poor at integrating memories
of experience with their assessment of the meaning of that experience.
Those dismissing of attachment deny or devalue early relationships.
Preoccupied individuals tend to be confused, and angry or passive
in their current relationships with their parents and others). Two studies
(Hamilton, 1994; Waters, et al., 1995) have shown a 68-75% correspondence
between attachment classifications in infancy and classifications in
adulthood. This work speaks to the remarkable stability of attachment
classifications across the lifespan. Similar findings are beginning
to emerge using other measures of attachment in adults (Hazan &
Zeifman, 1994).

3. The transgenerational transmission of attachment patterns

There is further important evidence that attachment relationships may
play a key role in the transgenerational transmission of hardship and
deprivation. Individuals categorised as secure are 3 or 4 times more
likely to have children who are securely attached to them (van Ijzendoorn,
1995). This turns out to be true even in prospective studies where parental
attachment is assessed before the birth of the child (Benoit & Parker,
1994; Fonagy et al., 1991; Radojevic, 1992; Steele et al.,
1996; Ward & Carlson,1995). These findings also emphasise the
importance of quality of parenting in determining the childs attachment
classification. The findings from our lab suggest that parental attachment
patterns predict variance in addition to temperament measures or contextual
factors, such as experience, social support, marital relationship, psychopathology
and personality (Steele, Steele & Fonagy, in preparation). If attachment
is linked to personality disorder we may anticipate a substantial overlap
between determinants of infant security and long-term predictors of
criminality.

3.1 Attachment and mentalising

A compelling model for the transmission of secure attachment, which
has moved the field beyond a simple view of caregiver sensitivity, was
suggested by Mary Main (1991) in her seminal chapter on metacognitive
monitoring and singular versus multiple models of attachment. Main (1991)
showed that the absence of metacognitive capacity, the inability to
"understand the merely representational nature of their
own (and others') thinking" (p. 128), makes infants and toddlers
vulnerable to the inconsistency of the caregiver's behaviour. They are
unable to step beyond the immediate reality of experience and grasp
the distinction between immediate experience and the mental state which
might underpin it. Main drew our attention to the development in the
child of the mental state that Dennett (1987) called "the intentional
stance". Dennett stressed that human beings are perhaps unique
in trying to understand each other in terms of mental states: thoughts,
feelings, desires, beliefs, in order to make sense of and, even more
important, to anticipate each others actions. It is self-evident
that by attributing an emotional or cognitive state to others we make
their behaviour explicable to ourselves. If the child is able to attribute
a withdrawing, non-responsive mother's apparently rejecting behaviour
to her emotional state of depression, rather than to himself as bad
and unstimulating, the child is protected from, perhaps permanent, narcissistic
injury. Perhaps even more central is the childs capacity to develop
representations of the mental states, emotional and cognitive, which
organise his/her behaviour toward the caregiver.

We attempted to operationalise individual differences in adults' metacognitive
capacities which we believe might help to fill the 'transmission gap'.
We were curious to know if the extent of self-reflective observations
about the mental states of self and others in Adult Attachment Interview
(AAI) narratives could predict infant security. We chose the term "reflective
self-scale" (as opposed to "self-reflection scale") to
underscore that we were concerned about the clarity of the individual's
representation of the mental states of others as well as the
representation of their own mental state.

Consistent with our expectation, reflective-self ratings were reliable
(intraclass r = .8 and above) and provided a good pre-natal prediction
of the Strange Situation behaviour of the child. Both fathers
and mothers who were rated to be high in this capacity were three or
four times more likely to have secure children than parents whose reflective
capacity was poor (Fonagy et al., 1991).

The capacity for metacognitive control may be particularly important
when the child is exposed to unfavourable interaction patterns, in the
extreme, abuse or trauma. For example, in the absence of the capacity
to represent ideas as ideas, the child is forced to accept the implication
of parental rejection, and adopt a negative view of himself. A child
who has the capacity to conceive of the mental state of the other can
also conceive of the possibility that the parent's rejection of him
or her may be based on false beliefs, and therefore is able to moderate
the impact of negative experience.

We examined this issue by administering a brief structured interview
to parents in our sample, 18 months after they had completed the Adult
Attachment Interview, concerning a number of simple indicators of
family stress and deprivation which had been reported in past studies
to increase dramatically the probability of adverse outcome, including,
in a recent study, the likelihood of insecure infant attachment. These
indicators included: single parent families residing separately, overcrowding,
paternal unemployment, etc. We divided our sample into those who had
reported significant experience of deprivation (more than 2 items) and
those who had not. Our prediction was that mothers in the deprived group
would be far more likely to have children securely attached to them
if their reflective-self rating (metacognitive capacity) was high.

10 out of 10 of the mothers in the deprived group with high reflective-self
ratings had children who were secure with them, whereas only 1 out of
17 of deprived mothers with low ratings did so. Reflective-self
function seemed to be a far less important predictor for the non-deprived
group. Our findings imply that the intergenerational replication of
early negative experiences may be aborted, the cycle of disadvantage
interrupted, if the caregiver acquires a capacity to fully represent
and reflect on mental experience (Fonagy et al., 1994).

3.2 Metacognitive monitoring and the development of the self

Metacognitive monitoring completes one aspect of the intergenerational
cycle. Not only are parents high in reflective capacity more likely
to promote secure attachment in the child, particularly if their own
childhood experiences were adverse, but also secure attachment may be
a key precursor of robust reflective capacity (Fonagy et al.,
1995).

In London, we have collected cross-sectional data from 3-5 year olds
which appears to indicate a strong correlation between security on a
projective measure of attachment (the SAT) and the early development
of a theory of mind, using the belief-desire reasoning task. We found
the children who were rated Secure on the Separation/Anxiety test were
more likely to pass the theory of mind tasks (Fonagy et al.,
1997). In a longitudinal study, we found that of 92 children, the 59
who had passed the task at 5 years, 66% were secure at one year with
their mother. Of the 29 who failed, only 31% had been secure. Attachment
security to father was less significantly associated with greater competence
at this task. There was clear indication that the reflective self function
of mother was associated with the childs success. 80% of children
whose mothers were above the median in reflective self function passed,
whereas only 56% of those whose mothers were below did so.

These results suggest that the parents' capacity to observe the child's
mind facilitates the child's general understanding of minds mediated
by secure attachment. The availability of a reflective caregiver increases
the likelihood of the child's secure attachment which, in turn, facilitates
the development of theory of mind. Throughout these studies we assume
that a secure attachment relationship provides a congenial context for
the child to explore the mind of the caregiver, and, as the philosopher
Hegel (1807) taught us, it is only through getting to know the mind
of the other that the child develops full appreciation of the nature
of mental states. The process is intersubjective: the child gets
to know the caregiver's mind as the caregiver endeavours to understand
and contain the mental state of the child.

The child perceives in the caregiver's behaviour not only her
stance of reflectiveness which he infers in order to account for her
behaviour, but also he perceives in the caregiver's stance an image
of himself as mentalizing, desiring and believing. He sees that
the caregiver represents him as an intentional being. It is this representation
which is internalised to form the self. "I think therefore I am"
will not do as a psychodynamic model of the birth of the self; "She
thinks of me as thinking and therefore I exist as a thinker" comes
perhaps closer to the truth.

If the caregiver's reflective capacity enabled her accurately to picture
the infant's intentional stance, the infant will have the opportunity
to "find itself in the other" as a mentalizing individual.
If the caregiver's capacity is lacking in this regard, the version of
itself that the infant will encounter will be an individual conceived
of as thinking in terms of physical reality rather than mental states.

4. Some speculations about pathological development based on the
dialectic model

The fundamental need of every infant is to find his mind, his intentional
state, in the mind of the object . For the infant, internalisation of
this image performs the function of "containment", which Winnicott
has written of as "giving back to the baby the baby's own self"
(Winnicott, 1967, p. 33) . Failure of this function leads to a desperate
search for alternative ways of containing thoughts and the intense feelings
they engender.

The search for alternative ways of mental containment may, we suggest,
give rise to many pathological solutions, including taking the mind
of the other, with its distorted, absent or malign picture of the child,
as part of the child's own sense of identity. Winnicott (1967) wrote:
"What does the baby see when he or she looks at the mother's face?
...ordinarily, the mother is looking at the baby and what she looks
like is related to what she sees there... [but what of] the baby
whose mother reflects her own mood or, worse still, the rigidity of
her own defences... They look and they do not see themselves... what
is seen is the mother's face" (p. 27).

This picture then becomes the germ of a potentially persecutory object
which is lodged in the self, but is alien and unassimilable. There will
be a desperate wish for separation in the hope of establishing an autonomous
identity or existence. However, tragically, this identity is centred
around a mental state which cannot reflect the changing emotional and
cognitive states of the individual, because it is based on an archaic
representation of the other, rather than the thinking and feeling self
as seen by the other.

Paradoxically, where the child's search for mirroring or containment
has failed, the later striving for separation will only produce a movement
towards fusion. The more the person attempts to become himself, the
closer he moves towards becoming his object, because the latter is part
of the self-structure. This in our view accounts for the familiar oscillation
of borderline patients, between the struggle for independence and the
terrifying wish for extreme closeness and fantasised union. Developmentally,
a crisis arises when the external demand for separateness becomes irresistible,
in late adolescence and early adulthood. At this time, self-destructive
and (in the extreme) suicidal behaviour is perceived as the only feasible
solution to an insoluble dilemma: the freeing of the self from the other
through the destruction of the other within the self.

In some individuals, for whom separateness is a chronic problem, we
assume that the experience of self-hood can only be achieved through
finding a physical other onto whom the other within the self can be
projected. Naturally, this increases the individuals need for
the physical presence of the object. Thus, many such individuals experience
considerable difficulty in leaving home and if they finally achieve
physical separation, they can only do so by finding an alternative and
comparable figure onto whom the other within the self may be projected.
If the other dies, or abandons the individual, a pathological mourning
process may be initiated whereby the person feels compelled to maintain
a live picture of the other, in order to retain the integrity of the
self.

Another possible outcome of poor development of the psychological self,
with consequent conflicts over separation, is that the body may be used
to contain and enact mental states. In these cases the child's own body
comes to serve the function of metarepresentation of feelings, ideas
and wishes. Violence towards the body of the self (e.g. self cutting)
or that of the other (apparently unprovoked aggression or mindless
violence may be a ways of controlling mental states
which are invested in bodily states (e.g. the mother seen as part of
ones own body) or destroying ideas experienced as within
the body of the other. In other young children the search for the psychological
self in the other may lead to the physical image of the object being
internalised as part of the child's identity. In extreme cases, this
may result in gender identity disorder (Fonagy & Target, 1995).

If the child finds no alternative interpersonal context where he is
conceived of as mentalizing his potential in this regard will not be
fulfilled. In cases of abusive, hostile or simply totally vacuous relationship
with the caregiver, the infant may deliberately turn away from the mentalizing
object because the contemplation of the object's mind is overwhelming
as it harbours frankly hostile intentions toward the infant's self.
This may lead to a widespread avoidance of mental states which further
reduces the chance of identifying and establishing intimate links with
an understanding object.

As studies of resilient children suggest, even a single secure/understanding
relationship may be sufficient for the development of reflective processes
and may 'save' the child. Metacognitive monitoring is biologically prepared
and will spontaneously emerge unless it's development is inhibited by
the dual disadvantage of the absence of a safe relationship and the
experience of maltreatment in the context of an intimate relationship.
We do not anticipate that trauma outside of the context of an attachment
bond would have pervasive inhibitory effects on mentalizing. It is because
the theory of mind or, more broadly, and reflective self function evolve
in the context of intense interpersonal relationships, that the fear
of the mind of another can have such devastating consequences on the
emergence of social understanding. To illustrate the clinical relevance
of this model, it may be helpful to consider borderline personality
disorder from the point of view of attachment theory.

4.1 A transgenerational model of borderline personality disorder

Although accurate figures are hard to come by and vary across studies,
considerable evidence has accumulated to support the contention that
child abuse is transmitted across generations. Oliver (1993), in his
recent review of 60 studies, mainly from the United States and the UK,
concluded that approximately one third of child victims of abuse grow
up to continue a pattern of seriously inept, neglectful or abusive child-rearing
as parents. Research has documented that a specific link exists between
the history of childhood maltreatment and borderline personality disorder
and sexual abuse is especially implicated. In brief, as infants and
children, borderline individuals frequently have caretakers who are
themselves within the so called 'borderline spectrum' of severely personality
disordered individuals. The social inheritance aspect of BPD may be
an important clue in our understanding of the disorder.

George Moran, Mary Target and I (Fonagy et al., 1993) have put
forward an attachment theory formulation of severe narcissistic and
borderline states based on epidemiological findings of the association
of severe personality disorder and a history of childhood maltreatment
and sexual abuse. We proposed that borderline individuals are those
victims of childhood (sexual) abuse who coped by refusing to conceive
of the contents of their caregiver's mind and thus successfully avoided
having to think about their caregiver's wish to harm them. They go on
to defensively disrupt their capacity to depict feelings and thoughts
in themselves and in others. This leaves them to operate upon inaccurate
and schematic impressions of thoughts and feelings and they are thus
immensely vulnerable in all intimate relationships.

Many of the symptoms of BPD individuals may be understood in terms
of a defensive strategy of disabling mentalizing or metacognitive capacity:

1. Their failure to take into consideration the listener's current
mental state makes their associations hard to follow.

2. The absence of concern for the other which may manifest as extreme
violence and cruelty, arises because of the lack of a compelling representation
of suffering in the mind of the other. A key moderator of aggression
is therefore absent. The lack of reflective capacity in conjunction
with a hostile world view may predispose individuals to child maltreatment
but such inhibition may be a necessary component of all violence against
persons. Military training has the apparent and explicit aim of fashioning
men into machines and the enemy into an inanimate or sub-human object.
Seeing the other as imbued with thought and feeling is very likely imposes
a break.

3. Their fragile sense of self (identity diffusion to use Kernberg's
term), may be a consequence of their failure to represent their own
feelings, beliefs and desires with sufficient clarity to provide them
with a core sense of themselves as a functioning mental entity. This
leaves them with overwhelming fears of mental disintegration and a desperately
fragile sense of self.

4. Such patient's mental image of object remains at the immediate context
dependent level of primary representations - he/she will need the object
as they are and will experience substantial difficulties when confronted
with change.

5. Absence of prominence 'as if' in the transference requires meta
representations, the capacity to entertain a belief whilst at the same
time knowing it to be false. Psychotherapy requires such pretence and
it's absence manifests as so called 'acting out' of the transference.

4.2 The association of attachment status and borderline states

In an ongoing study (Fonagy et al., 1996) we administered AAI's
to a sample of 85 consecutively admitted non-psychotic inpatients at
the Cassell Hospital in London, which is run along the principles of
a psychoanalytic therapeutic community. About 40% of the patients met
diagnostic criteria for borderline personality disorder (BPD) on the
basis of a structured interview (SCID-II).

The distribution of AAI classifications arrived at totally independently
of the diagnostic process, did not distinguish well Borderline Personality
Disorder (BPD) from other personality disorder diagnoses but the number
of entangled (particularly E3) classifications were well above the number
which would be expected by chance (75%).

Borderline patients' interviews were, however, differentiated by a
combination of 3 characteristics:

(3) a significantly higher rating on the lack of resolution of abuse,
but not loss scale of the AAI.

Further, there was a significant interaction between abuse and RSF:
individuals with experience of abuse who had low RSF were very likely
to have a diagnosis of BPD.

These findings are consistent with our assumption that individuals
with experience of severe maltreatment in childhood who respond to this
experience by an inhibition of reflective self function are less likely
to resolve this abuse, and are more likely to manifest borderline psychopathology.

Childhood maltreatment may or may not have long term sequelae and the
determinants of the outcome are only partially understood. Here we propose
that if children are maltreated but they have access to a meaningful
attachment relationship which provides the intersubjective bases for
the development of mentalising capacity, they will be able to resolve
(work through) their experience and the outcome of the abuse will not
be one of severe personality disorder. We do not expect that their reflective
processes will protect them from episodic psychiatric disorder, such
as depression, and epidemiological data suggests that victims of childhood
maltreatment are at an elevated risk for many forms of [Axis-I] disorder.

However, if the maltreated child has no social support of sufficient
strength and intensity for an attachment bond to develop which could
provide the context for the acquisition of a reliable capacity to envisage
the psychological state of the other in intense interpersonal relationships,
then the experience of abuse will not be reflected on or resolved. Naturally,
the unresolved experience of abuse diminishes the likelihood of meaningful
relationships which, in a self-perpetuating way, further reduces the
likelihood of a satisfactory resolution of the disturbing experience
through the use of reflective processes. In fact a pattern may be established
whereby suspicion and distrust generalises and leads to a turning away
from the mental state of most significant objects and an apparent 'decoupling'
of the 'mentalizing module' leaving the person bereft of human contact.
This may account for the 'neediness' of borderline personality disordered
individuals; yet no sooner do they become involved with another then
the malfunctioning of their inhibited mentalising capacity leads them
into terrifying interpersonal confusion and chaos. Within intense relationships
their inadequate mentalising function rapidly fails them, they regress
to the intersubjective state of the development of mental representation
and they are no longer able to differentiate their own mental representations
from those of others and both of these from actuality. These processes
combine and they become terrorised by their own thoughts about the other
experienced (via projection) in the other, particularly their
aggressive impulses and fantasies ; these become crippling and most
commonly they reject or arrange to be rejected by their object. Psychoanalysis
or psychotherapy can break the vicious cycle by reinforcing reflective
capacity.

5. Crime, violence and attachment

As with borderline patients, a history of maltreatment is present in
80-90% of juvenile offenders and approximately a quarter of those with
histories of severe maltreatment are likely to have criminal convictions
(e.g. Taylor, 1986). We have suggested that attachment to individuals
as well as social institutions may be critical in reducing the risk
of delinquency and adjustment processes are severely disrupted by childhood
maltreatment. More specifically, if attachment to the primary caregiver
is intimately linked to the acquisition of reflective capacity (see
section on moral development, above), the latter may be a key mediator
in predisposing an individual to criminality, particularly to violent
offences. We may suppose that those individuals, who were never exposed
to interpersonal relationships where the acquisition of a reflective
capacity would have been facilitated, or who were exposed to caregiving
environments where their only route to adaptation was the inhibition
of mentalizing, are most likely to develop insecure attachments and
manifest low reflective capacities, thus removing essential inhibitions
on criminal activities. The capacity to envision the mental state of
the potential victim may be essential in preventing us from deliberately
harming other members of our social group (or species).

To put these ideas to a test, Levinson & Fonagy (in preparation)
collected AAIs from 22 prisoners (convicted or on remand with
diagnosable psychiatric disorder) and matched them with 2 control groups
on age, gender, social class and IQ: 1) a psychiatric inpatient control
group matched for diagnoses (Axis I/II) and 2) a normal control group
recruited from a medical outpatient department. The findings may be
summarised as follows:

(1) There was significantly more secure attachments in the normal control
group but the two clinical groups did not differ in terms of overall
level of security.

(2) 36% of the prison group vs. 14% of the psychiatric group were classified
as Dismissing with normal controls in between (23%).

(3) 45% of the prisoners vs. 64% of psychiatric controls were classified
as Preoccupied with only 14% of non-criminal controls receiving
this classification.

(4) 82% of psychiatric patients but only 36% of prisoners and 0% of
non-clinical controls received Unresolved classifications.

(5) 82% of prisoners and only 36% of psychiatric patients were rated
as having been abused with only 4% of normal controls. (2/3 of abuse
was physical, 1/3 sexual in both clinical groups).

(6) Neglect was more prevalent in the prison group but rejection was
more frequently reported by psychiatric patients.

(7) Current anger with attachment figures was dominant in psychiatric
patients but relatively more among prisoners.

(8) Prisoners had significantly lower ratings on the reflective function
scale (RSF) than either psychiatric patients or those from the non-clinical
group, but RSF ratings of normals was still significantly higher than
those of psychiatric patients.

(9) When the prison group was split into those with violent index offences
(murder, malicious wounding, GBH, armed robbery, indecent assault to
child), vs. non violent ones (possession, importation, obtaining property
by deception, theft, handling stolen goods) the rating on reflectiveness
of the former group was found to be significantly lower than the latter.

This pattern of results is consistent with our assumption that criminality
arises in the context of weak bonding with individuals and social institutions
and the relatively ready dismissal of attachment objects. Criminal behaviour
may be seen as a socially maladaptive form of resolving trauma and abuse
(which was almost ubiquitous in our small sample). Violent acts are
committed in place of experienced anger concerning neglect, rejection
and maltreatment. Committing antisocial acts is facilitated by a non-reflective
stance of the victim which may be of particular significance in cases
where the victim is clearly identifiable as in violent acts against
another person.

This is only a pilot investigation, but the results are promising to
the extent that they link attachment related narratives to the nature
of the offence committed. Naturally, an important alternative account
to the one proposed here may be that it was these crimes which caused
the disorganisation of the attachment system and it was the psychological
impact of crime which permeated the interviews of the violent group.
The less serious offences may have made less impact on the representation
of relationships.

6. Psychotherapy and mentalising

Clinical psychoanalysis inevitably deals with individuals whose past
experience has left them vulnerable to current stress and the repetition
of adverse early experiences. The treatment imposes a non-pragmatic
elaborative, mentalistic stance. This enhances the development of reflective
self function and may in the long run enhance the psychic resilience
of individuals in a generic way, providing them with improved control
over their system of representation of relationships. It equips them
with a kind of self-righting capacity where through being able to operate
on their representational models, the latter can become an object of
review and change. Such gradual and constant adjustments facilitate
the development of an internal world where the behaviour of others may
be experienced as understandable, meaningful, predictable and characteristically
human. This reduces the need for splitting of frightening and incoherent
mental representations of mental states, and new experiences of other
minds can more readily be integrated into the framework of past relationship
representations.

The abused child, evading the mental world, never acquires adequate
meta-control over the representational world of internal working models.
Unhelpful models of relationship patterns emerge frequently and the
internal world of the child and adult comes to be dominated by negative
affect. The individual's enhanced suspiciousness of human motives reinforces
his/her strategy to forego mentalizing, thus further distorting the
normal development of a reflective function. Caught in a vicious cycle
of paranoid anxiety and exaggerated defensive manoeuvres, the individual
becomes inextricably entangled into an internal world dominated by dangerous,
evil and above all mindless objects. He has abnegated the very process
which could extract him from his predicament, the capacity to reflect
on mental states.

Psychotherapeutic treatment in general, and psychoanalytic treatment
in particular, compels the patient's mind to focus on the mental state
of a benevolent other, that of the therapist. The frequent and consistent
interpretation of the mental state of both analyst and patient (i.e.
the interpretation of the transference in the broadest sense) is then
desirable, if not essential, if the inhibition on this aspect of mental
function is to be lifted. Over a prolonged time period, diverse interpretations
concerning the patient's perception of the analytic relationship would
enable him to attempt to create a mental representation both of himself
and of his analyst, as thinking and feeling. This could then form the
core of a sense of himself with a capacity to represent ideas and meanings,
and create the basis for the bond that ultimately permits independent
existence.

7. Summary

The paper puts forward an attachment theory model of severe
personality disturbance. It is suggested that

(1) secure attachment is the basis of the acquisition of
metacognitive or mentalizing capacity;

(2) the caregivers capacity to mentalize may foster
the childs bonding with the parent;

(3) maltreatment may undermine the acquisition of a mentalizing
capacity;

(4) symptoms of borderline personality disorder may arise
as a consequence of inhibited mentalizing;

(5) violent crime and anti-social personality disorder may
be possible because the capacity to reflect upon the mental states
of the victim is compromised;

(6) psychotherapeutic work may facilitate the reactivation
of this inhibited capacity.

Main M., & Weston D. (1981). The quality of the toddler's
relationship to mother and to father: Related to conflict behavior and
the readiness to establish new relationships. Child Development,
52, 932-940.

Maslin C.A. and Bates J.E. (1983). Precursors of anxious
and secure attachments: A multivariant model at age 6 months. Paper
presented at the biennial meeting of the Society for Research in Child
Development: Detroit, MI.

Radojevic M. (1992). Predicting quality of infant attachment
to father at 15 months from pre-natal paternal representations of attachment:
an Australian contribution. Paper presented at the 25th International
Congress of Psychology: Brussels, Belgium.

Waters E., Merrick S., Albersheim L., Treboux D. & Crowell,
J. (1995). From the Strange Situation to the Adult Attachment Interview:
A 20-year Longitudinal Study of Attachment Security in Infancy and Early
Adulthood. Presented at meeting of the Society for Research in Child
Development: Indianapolis, IN.

Winnicott D. W. (1967). Mirror-role of the mother and family
in child development. In P. Lomas (editor), The Predicament of the
Family: A Psycho-Analytical Symposium. London: Hogarth, pp. 26-33.